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PatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

The gastrointestinal tract extends from the lips to the anus and includes the liver, biliary system and pancreas although, for the purpose of this article, consideration will start at the oesophagus, as problems with dentition or with salivary gland disorders and tumours are covered elsewhere.

General principles

Ask open questions and give the patient time to elaborate. However, it is very important to ascertain that you are 'speaking the same language'. Avoid technical terms, jargon or abbreviations. Make sure that you understand what the patient means and get amplification of specific points. To patients, the word 'stomach' can mean anywhere from the diaphragm to the groin and includes the genitals. 'Do you have a hard stool?' may make the patient wonder if the chair in the kitchen is comfortable. Does 'coughing up blood' mean haemoptysis or haematemesis? Patients often describe pain as 'chronic', meaning severe rather than of long-standing duration.

Elucidation of specific points

The following are important aspects of the history, which require clarification:

Dysphagia

What does difficulty in swallowing mean? Dysphagia has many components.

Is there pain?

Is there a feeling of obstruction?

Is food regurgitated? If so, how long after swallowing?

Is it a burning pain just after eating?

If there is complaint of obstruction, ask the patient to point to the level. The obstruction is usually at that level or below.

Globus hystericus is usually accompanied by a rather theatrical performance and, unlike neurological disorders, the patient denies being able to swallow anything but does not drown in their own saliva and often has not lost weight.

Systematic enquiry

If so, is this intentional? Distinguish dieting from abnormal weight loss.

How much and over what period of time?

Not everyone watches their weight. Are waistbands any tighter or looser than before? Loss of weight means malnutrition.

Weight gain and expansion will accompany an enlarging abdominal mass or ascites.

When seeing females aged between about 12 and 50 years record the date of the last menstrual period. Failure to do so with subsequent failure to diagnose a mass arising from the pelvis will cause immense embarrassment.

Ask about smoking and alcohol consumption. If there is any reason to suspect excessive consumption of alcohol, refer to information under alcoholism for diagnosis and management in primary care, help and advice.

Replies like 'I just drink socially' are meaningless, as they depend upon the company one keeps.

Establish whether the patient drinks every day.

Record exact amounts smoked and drunk and, if a range is given, record the upper figure, as it is more likely to be accurate.

Ask about medication and make it clear that this means not just prescribed medication but drugs bought over the counter, 'alternative remedies' and illicit drugs.

Anabolic steroid abuse can cause hepatitis and even hepatocellular carcinoma.

Establish in what form drugs are taken. Non-steroidal anti-inflammatory drugs as suppositories may still cause gastritis, as the drug is transported to the stomach in the blood. There is also a high risk of proctitis.

The patient may admit to visiting health spas and receiving colonic lavage or high colonic irrigation.

If there is proctitis, a delicate enquiry as to the person's sexual predilection may be required in both males and females.

Ask whether the patient eats a normal diet. Changes in eating habits may have resulted from the symptoms.

Note family history.

Ask about foreign travel and living abroad. Traveller's diarrhoea is just one possibility. Many other exotic diseases can be acquired.

Note the angles of the mouth. Angular cheilitis may suggest iron deficiency. In pernicious anaemia around 50% of patients have a smooth tongue with loss of papillae but this can also be due to friction in those with a plastic palate with upper dentures.

Note whether the mouth looks healthy.

Note whether dentition is good.

Note whether there is halitosis.

Oral candida may be associated with oesophageal candidiasis, especially if immunity is suppressed.

Only now is it time to turn to the abdomen and, as always, first look.

Abdominal distension may be apparent.

Abdominal masses may be apparent on inspection.

High pressure in the abdomen may cause protrusion of the umbilicus. Cirrhosis or portal hypertension may produce prominent blood vessels on the abdomen.

Now it is time for palpation and, again, reference is made to examination of the abdomen, which also includes palpating for splenomegaly and detection of ascites. Hepatomegaly can be difficult to detect and it is often useful to percuss the liver edge. The liver is dull to percussion while bowel is resonant.

Check for herniae. Femoral hernia is uncommon but very liable to strangulate.

In secondary care the dictum is that no abdominal examination is complete without rectal examination. In primary care this is less vigorously applied, especially if the findings are unlikely to affect management.

Few GPs have the skills or resources for sigmoidoscopy but proctoscopy and digital rectal examination should be within the capacity of everyone.

Such examination may reveal rectal prolapse or an obvious cause of rectal bleeding, although haemorrhoids are so common that they do not exclude other causes of bleeding.

Carcinoma of the rectum may well be palpable.

If an elderly person has diarrhoea, it is a distinct possibility that it is really spurious diarrhoea caused by faecal impaction with overflow. Therefore, before starting medication that may aggravate constipation, it is imperative to perform a rectal examination. The old adage is 'Put your finger in it before you put your foot in it.'

Differential diagnosis

This includes two important aspects:

Be aware of the warning signs that may indicate malignancy:

Malignancy should be considered with significant, unintentional weight loss, progressive dysphagia, chronic blood loss, persistent vomiting and change of bowel habit in excess of six weeks' duration, especially over the age of 40.

Children vomit very easily and are often remarkably unperturbed by it. Parents will recall how a child has vomited during a meal and, before they have finished clearing it up, the child is eagerly finishing the meal.

Vomiting with a high temperature, unrelated to the gastrointestinal tract, is common.

The frequency of defecation in milk-fed babies is extremely variable as there is little residue, especially if they are breast-fed.

If children are asked where it hurts, they usually point to the umbilicus, even if the primary lesion is tonsillitis or otitis media.

Examination of children also presents special difficulties. These are covered in the separate Paediatric Examination article.

If rectal examination is required for a baby, use the little finger, as it is smallest. Think carefully before performing a rectal examination on an older child, as it may be as traumatic as sexual abuse.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.